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Objectives
Recognize the importance of symptom management for psychiatric patients Gain understanding of psychiatric diagnoses and associated symptoms Identify patients at high risk for suicidality or agression Learn specific strategies for dealing with a variety of behavioral issues Identify characteristics of special populations
Persecutory delusions
command auditory hallucinations
1. Who or what do you believe wants to harm you? 2. How is this person attempting to harm you? (Ask about specific threat/control-override beliefs)
3. How certain are you that this is happening? 4. Is there anything that could convince you that this isnt true? 5. How does your belief make you feel (eg, unhappy, frightened, anxious, or angry)?
6. Have you thought about any actions to take as a result of these beliefs? If so, what? 7. Have you taken any action as a result of your beliefs? If so, what specific actions? 8. Has your concern about being harmed stopped you from doing any action that you would normally do? Have you changed your routine in any way? 9. How much time do you spend thinking about this each day? 10. In what ways have these beliefs impacted your life?
Specific Strategies:
o AVOID POWER STRUGGLES! o Give choices as often as possible; clear, reasonable limits o Dont react emotionally to behaviors, know your own buttons o No punitive treatments, threats, ultimatums or excessive restrictions-they will give the patient a reason to escalate
o Spend time (if you can) talking with the patient to find out what they need and want; try to accommodate them if you are able (explain why if you cant) o Be aware of non-verbal communication o Explain the process involved, try to decrease anxiety as much as possible o Check back with the patient often o Expedite process of evaluation
o Low stimulus, keep directions/statements short and simple (may have to repeat them) o Dont argue with the pt.; say youre right as much as possible in order to make it easier to set limits when necessary o Medicate early for agitation, get a reliable sitter o New onset mania needs medical workup and probably hospitalization o Assume patient will be unpredictable and plan for it o Check medication levels
o Approach slowly, using non-threatening body language o Dont feed into delusions, but dont directly contradict them either e.g. That sounds very frightening. o Ask about voices, what they are saying, how the patient feels about them (some are friendly voices) o Assess cognitive functioning to determine level of disorganization
o If the patient is there due to safety issues, ask what would be helpful to them to feel safe o Low stimulus, medicate for agitation, consider medical etiology if new symptoms o New onset? Plan for hospitalization and family education
o Ask what they need from ER visit, explain options e.g. connect with services o Assess extent of depression to avoid excessive restrictions o Be kind, explain what is happening; give reassurance that you want to help them. o Specifically ask what would be most helpful to them
o Offer food, warmth, comfort; may need to ask more than once o Ask about stressors, supports, therapists, allow family/friends if patient wants them o Ask about (vague thoughts vs. plan with intent, can help pinpoint how far the depression has progressed)
o Recognize, treat the physical symptoms as real o Assess the patients understanding of what is happening o Offer reassurance e.g. I know you are frightened but we are going to take care of you.
o Needle phobias, hyperventilation o Ask what has worked for them in the past when dealing with their anxiety o Family/friends involvement o Humor, distraction are helpful with mildmoderate anxiety
o Listen in a nonjudgmental way, avoid offering advice o Check with patient before allowing visitors, phone calls o Safety contract o Explain to pt. what the process involved in formal assessment
Summary
Both patients and staff benefit when we: Understand psychiatric diagnoses Anticipate, manage and prevent symptoms Avoid punitive, controlling strategies Increase cooperation by establishing a therapeutic rapport and alliance
And finally
References: 1. Gilbert, Sara Barr. Psychiatric Crash Cart: Treatment Strategies for the Emergency Department. Advanced Emergency Nursing Journal. 31(4):298-308, October/December 2009. 2. Stefan, Susan, Emergency Department Treatment of the Psychiatric Patient: Policy Issues and Legal Requirements, Oxford University Press, 2006. 3. National Alliance for Mental Health, www.nami.org 4. Psychiatric Services, www.psychservices.psychiatryonline.org 5. Help Guide, www.helpguide.org/mental
Many Thanks